Mar 29, 2010

Amputations

I never thought much about amputations. They are common surgeries, most often related to uncontrolled diabetes, and seemed routine and unremarkable to me.

I've had the experience of witnessing several amputations while in my surgical service, all diabetes-related. Each time it surprises me with the sense of loss that comes with the amputation of a toe, a foot, a leg. I had never really considered the emotional impact of losing a limb. To be honest, I sort of thought that amputation resulted from a lack of self-control; the inability of the patient to monitor their glucose levels and make changes. Not to say that anyone deserves this sort of pain, but it seemed like a correlation between sugar and limb loss equaled a well-documented and preventable consequence. And then I had a black foot staring at me from a sterile blue-shrouded operating table.

I looked at it, and it looked at me, and I thought about all the things it had done for that person over the course of their life, how it was part of the patient. Bodies last longer than people, and it's natural to think that the body remains intact throughout ones' life. The operation to remove it reflects the difficulty, the tense dichotomy of this separation. It is a very physical removal- powered bone saws, strong manual bone cutters, and large scissors coarsely separate the limb from the proximal tissues. Nothing is pretty, edges are not delicately sewn. The necrotic tissue is essentially ripped from the living person.

And then you are left with a toe sitting on the OR table; a foot without an owner. You look at it and think "that was just attached a moment ago. Now it's just sitting there." You think about the extension of the person that it was- a baby's tiny toe, taking a first step, running, stubbed, swimming, carefully painted- and the gaping hole that is left from the amputation reflects the loss of something that helped shape a life. It always seems wrong to me to bandage up the stump without the limb, like the surgeon forgot something.

Even as these surgeries seem in contradiction with life, they are performed so people may live. A missing foot is a small price to pay for the excision of gangrene. There is a picture of me (on my second birthday) and my grandfather, who looks absolutely enamored with his granddaughter. He died a few months after this picture was taken. After hearing about my emotional reaction to the excision of a limb, my dad sent this picture to me. He gently reminded me that this precious moment with his granddaughter would not have been possible if he hadn't had the operations to remove a diabetic gangrenous foot and leg.

This is the glory and curse of the surgeon: you either cure or kill. The operating room is the fastest place in the hospital to make a difference in the long term prognosis of a patient. It's not for me- I like ongoing relationships with (awake) patients- but I can appreciate the meaningful work of the surgeon.